Introduction

Hospitalised patients with UC are likely to be on biologics or small molecule therapy (BST). The diversity of treatment options may contribute to delays in identifying medically refractory disease. Additionally, there may be scope for earlier introduction of advanced therapies.

Aims & Methods

We aimed to compare outcomes between patients previously treated with biologics to those who were BST naive. We conducted a retrospective analysis of patients aged >18 years, admitted between December 2022 and August 2023, with left-sided or extensive colitis. Inclusion criteria were intravenous steroid treatment, length of stay >72 hours, elevated CRP, and stool frequency >4/day. Proctitis and infectious colitis were excluded.

Results

Thirty-eight patients met inclusion criteria: 13 (34%) were BST experienced and 25 (66%) naïve. Of the latter, 10 (40%) were admitted within the first year of diagnosis, and 16 (64%) required rescue therapy. Additionally, left-sided colitis was more prevalent in the BST naïve group (p=0.005). There was one death in this cohort; a patient who suffered post-operative complications of stroke and sepsis after colectomy.The BST group comprised of 4 patients on infliximab (31%), 4 on vedolizumab (31%), 3 on adalimumab (23%), 1 on ustekinumab (8%), and 1 on tofacitinib (8%). Of these, 8 (62%) were on first-line agents, 3 (23%) on second-line, 1 on third-line, and 1 on a fourth-line agent at admission. Gastrointestinal infections were not over represented in this group (n=0).Surgery rates were significantly higher in the BST exposed group: 4 (31%) underwent surgery within a month of admission, compared to 1 (4%) in the BST naïve group (p=0.02). There was a greater proportion of patients on second or third-line BST v/s first line (3 of 4 patients) among the surgical group but serum CRP, albumin, Oxford criteria and UCEIS did not seem to predict risk of surgery.

Conclusion

Our data suggests effective protocolised management of severe UC. Patients receive timely rescue therapy, and colectomy rates are consistent with best practice. On the other hand, the high proportion of BST naive patients admitted with severe symptoms within the first year of presentation could indicate scope for earlier introduction of outpatient BST. The preponderance of lower risk factors such as left sided disease and lower CRP levels in this group could support a shift in emphasis from first line parenteral biologics and its inherent pharmacy logistical limitations to oral small molecule therapy for earlier remission rates. The number of BST experienced patients on anti TNF (50%) may indicate potential for earlier out of class switch to newer small molecule drugs. The relative insensitivity of high-risk features such as CRP and UCEIS among the BST experienced patients highlights the need for specialist management of medically refractory disease. The higher prevalence of limited colitis in the BST naive may indicate a bias towards later introduction of advanced therapies as an outpatient. A larger data set will provide useful insights into the care of this increasingly prevalent cohort of UC patients.

Introduction

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective treatment for patients in whom transpapillary biliary drainage fails. However, EUS-HGS is associated with a high incidence of early procedure-relatedadverse events (PRAEs) due to bile leakage through a biliogastrointestinal fistula.

Aims & Methods

This multicenter study retrospectively evaluated the clinical outcomes of EUS-HGS. This study included 222 patients (120 men, 102 women; median age, 73 years) who underwent initial EUS-HGS between November 2014 and August 2024. Technical and clinical success rates, PRAEs, and stent dysfunction rates were analyzed. PRAEs were defined as adverse events occurring within 2 weeks according to the assessment of the American Society for Gastrointestinal Endoscopy.

Results

Benign and malignant tumors were observed in 18 (8.1%) and 204 (91.9%) patients, respectively. The median procedure time for EUS-HGS was 41 min (range, 11–173 minutes). Plastic and metal stents were deployed in 51.4% and 48.6% of the patients, respectively. Technical and clinical success rates and PRAEs were 97.8%, 85.1%, and 22.1%, respectively. The PRAEs were classified into mild (16.7%), moderate (4.1%), or severe (1.4%). Recurrent biliary obstruction (RBO) occurred in 51 (23.1%) patients. The median time to RBO in the metal stent group was significantly longer than that in the plastic stent group (313 vs. 162 days, P=0.02). Multivariate analysis identified the use of any dilation device (P=0.01; odds ratio [OR]: 3.55; 95% confidence interval [CI]: 1.35–9.36) and concomitant antegrade stenting (P=0.03; OR: 2.62; 95% CI: 1.12–6.12) as risk factors for PRAEs.

Conclusion

EUS-HGS is feasible; however, careful follow-up is required for patients undergoing fistula dilation and concomitant antegrade stenting.

Introduction

Current colonoscopy quality indicators recommend a minimum withdrawal time (WT) of 6 minutes. However, this standard may reduce colonoscopy efficiency and does not account for endoscopists' experience or bowel preparation quality. This study aims to investigate whether the 6-minute WT remains necessary for experienced endoscopists with excellent bowel preparation (BBPS≥8) by comparing the impact of 5-minute versus 6-minute WT on adenoma detection rate (ADR) and adenoma miss rate (AMR).

Aims & Methods

This study based experienced endoscopists and excellent bowel preparation (Boston Bowel Preparation Scale score, BBPS≥8) is aimed to compare the effect of 5-minute WT versus 6-minute WT on adenoma detection rate (ADR) and adenoma miss rate (AMR).
This multicenter, randomized controlled trial involving 423 patients was conducted from June 2023 to March 2025 in 5 centers, including Wuxi People's Hospital, Jiangsu Province People's hospital, Xuzhou First People's Hospital, The Second Affiliated Hospital of Soochow University, Taizhou People's Hospital. Colonoscope was inserted and withdrew twice on each patient and all procedures for the same patient were done by the same endoscopist. Participants were randomly divided into the 5-minute WT group (the first WT-5-minute and the second WT-6-minute, n =214) and the 6-minute WT group (the first WT-6-minute and the second WT-6-minute, n=209), and a timer was used to adjust the withdrawal speed. The primary outcome was ADR and AMR.

Results

The baseline characteristics of the two groups were similar (Table 1) and colonoscopy characteristics of the patients in the two groups regarding quality of bowel preparation, cecal intubation rate, cecal intubation time, cecal intubation distance, number of abdominal compression, number of position change were comparable (Table 2). Overall ADR (39.7% vs 43.5%, P = 0.425), ADR in the first (36.0% vs 36.4%, P = 0.935) and second withdrawal (10.7% vs 13.9%; P = 0.327) were not significantly increased in the 6-minute WT group compared with the 5-minute WT group. Likewise, the overall advanced adenoma detection (AADR) (4.7% vs 5.3%, P = 0.780), AADR in the first (4.7% vs 5.3%, P = 0.780) and second withdrawal (0.5% vs 0.5%, P = 0.745) did not differ statistically. Further analysis showed that AMR (10.7% vs 13.9%, P = 0.372) was lower in the 5-minute WT group than in the 6-minute WT group, less adenomas were missed in the 5-minute WT group, although not statistically significant (Table 3).
Table 3. Lesion-level detection and miss rate in the two groups
PDR, polyp detection rate; ADR, adenoma detection rate; AADR, advanced adenoma detection rate; AMR, adenoma miss rate; AAMR, advanced adenoma miss rate; PMR, polyp miss rate.
Table 3. Lesion-level detection and miss rate in the two groups

Conclusion

Shortening WT from 6 to 5 minutes didn't reduce ADR based experienced endoscopists and excellent BBPS, a 5-minute WT benchmark was acceptable with experienced endoscopists and excellent bowel preparation quality of colonoscopy.

Introduction

Accurate prediction of lymph node metastasis (LNM) in submucosal invasive (T1) colorectal cancer (CRC) is essential for determining the need for additional surgery following endoscopic resection. Conventional histopathological assessments, however, are limited by interobserver variability. This study aimed to develop and externally validate a stacking-based artificial intelligence (AI) model integrating histopathological whole slide images (WSIs) and clinical parameters to predict the risk of LNM in T1 CRC.

Aims & Methods

This retrospective study included 1,056 patients with histologically confirmed T1 CRC treated at Showa Medical University Northern Yokohama Hospital. Of these, 593 cases were used for model training and 100 for internal testing. External validation was conducted on 25 cases from two independent institutions.
The proposed stacking ensemble model incorporated the Multiple Instance Self-Training (MIST) score derived from WSIs, patient sex, and tumor location (colon vs. rectum). Base learners included logistic regression, XGBoost, and random forest, with a meta-learner synthesizing their outputs to generate the final LNM prediction. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) in both internal and external cohorts.

Results

LNM was observed in 69 (11.6%) training cases, 15 (15.0%) test cases, and 2 (8.0%) external validation cases. The model achieved an AUC of 0.6965 in the internal test cohort and 0.7500 in the external validation cohort, demonstrating stable and generalizable predictive performance.
A representative case involved a 64-year-old man with a 16-mm type 0-Is lesion in the sigmoid colon resected via endoscopic mucosal resection (EMR). Histopathology showed well-differentiated tubular adenocarcinoma (tub1 > tub2), submucosal invasion depth of 3,300 µm (T1b), tumor budding grade BD1, Ly0, V1a, and negative resection margins (HM0, VM0). Despite guideline-based recommendations prompting additional surgical resection, no LNM was found (N0, 0/16), and the patient remained recurrence-free five years postoperatively—consistent with the AI model’s prediction.

Conclusion

The stacking-based AI model exhibited robust and generalizable performance in predicting LNM in T1 CRC, both internally and across external institutions. This approach offers a complementary tool to conventional pathology and may enhance individualized decision-making regarding the necessity of additional surgical intervention.

Introduction

The lymphocyte-to-monocyte ratio (LMR) is widely utilized as a surrogate marker of systemic inflammation and is increasingly recognized as an indicator of immune status within the tumor microenvironment, particularly in the setting of cancer immunotherapy.

Aims & Methods

^​​​​​This study aimed to evaluate the prognostic relevance of LMR in patients undergoing combination therapy with durvalumab (Dur) and tremelimumab (Tre) for unresectable hepatocellular carcinoma (uHCC). A total of 242 patients with uHCC who received Dur/Tre therapy at multiple institutions between February 2023 and March 2025 were retrospectively analyzed. Inclusion criteria encompassed available baseline LMR, Child-Pugh class A liver function, and complete clinical data. Patient characteristics were as follows: median age 74.0 years (IQR: 68.3–77.0); sex distribution, 202 males and 40 females; performance status (PS) 0/1/≥2: 201/32/9; underlying liver disease (HBV/HCV/HBV+HCV/NBNC): 37/72/1/132; BCLC stage (≤A/B/≥C): 19/68/155; Child-Pugh score (5/6): 125/117; alpha-fetoprotein (AFP) level: 57.6 ng/mL (IQR: 4.3–909.8); LMR: 3.14 (2.18–4.15); treatment line (first-/second-line): 94/148; and median observation period: 9.0 months (5.0–14.2).

Results

The median progression-free survival (PFS) and overall survival (OS) were 3.5 months (2.8–4.3) and 19.2 months (15.4–NA), respectively. Time-dependent ROC analysis identified 2.15 as the optimal LMR cutoff at 25% of the observation period (15.4 months). Objective response rates per RECIST version 1.1 were as follows: complete response (CR), 3.2%; partial response (PR), 15.5%; stable disease (SD), 32.4%; and progressive disease (PD), 48.9%. Disease control rate (DCR) was significantly higher in the LMR ≥2.15 group compared to the <2.15 group (55.4% vs. 37.3%, p = 0.026). Patients with LMR ≥2.15 demonstrated significantly longer PFS (3.8 months [95% CI: 3.8–4.6] vs. 2.7 months [95% CI: 2.00–4.00]; p= 0.005) and OS (NA months [95% CI NA: –17.9] vs. 13.2 months [95% CI: 8.5–17.1]; p = 0.005). In multivariate analysis using the Cox proportional hazards model, LMR ≥2.15 emerged as an independent predictor of both PFS (HR = 0.622; 95% CI: 0.438–0.884; p = 0.008) and OS (HR = 0.558; 95% CI: 0.328–0.949; p = 0.031). Hazard ratio approximation curves indicated that the range of LMR associated with significant prognostic impact on both PFS and OS was approximately 1.6 to 2.4. Subgroup analysis further demonstrated that in first-line treatment settings, patients with LMR ≥2.15 had superior PFS and OS outcomes compared to those with LMR <2.15 (PFS: p = 0.028; OS: p = 0.016).

Conclusion

​​​​LMR serves as a valuable prognostic biomarker in patients receiving Dur/Tre combination therapy for uHCC, with potential utility in guiding therapeutic decision-making.

Disclosure

Toshifumi Tada: lecture fees from AbbVie, Eisai, and Chugai
Atsushi Hiraoka: lecture fees from Eisai, Bayer, Eli Lilly, and Otsuka
Hidenori Toyoda: lecture fees from AbbVie, Eisai, Gilead, Terumo, and Bayer

Introduction

The management of malignant hilar biliary obstruction can be done by endoscopic biliary stenting, which is a well-established palliative treatment, improving the quality of life by relieving symptoms.

Aims & Methods

This systematic review and meta-analysis aimed to compare the use of stents placed above and across the sphincter of Oddi in patients with malignant hilar biliary obstruction. We performed a systematic search of the PubMed, Embase, and Cochrane Library databases in April 2025. Article screening was conducted independently by two authors using Rayyan software. Inclusion criteria were randomized controlled trials (RCTs) comparing stent placement above and across the sphincter of Oddi for malignant hilar biliary obstruction, evaluating at least one of the outcomes of interest. The outcomes were stent migration, stent patency, cholangitis, stent occlusion, and successful placement of the stent. RStudio software was used for statistical analysis, applying a random-effects model to calculate the risk ratio (RR) in binary outcomes and mean differences (MD) in continuous outcomes.

Results

We included three RCTs comprising 161 patients. There was no significant difference between the transpapillary and suprapapillary stents regarding the rates of stent migration (RR 2.03; 95% CI 0.41–10.16; p=0.39; I²=55%), cholangitis (RR 0.65; 95% CI 0.08–5.07; p=0.68; I²=0%), technical success (RR 0.99; 95% CI 0.95–1.04; p=0.80; I²=0%), and stent occlusion (MD 89.20; 95% CI 16.30–162.10; p=0.02; I²=78%). However, the mean number of patent stents was significantly lower in the suprapapillary stent group.

Conclusion

The two types of stent seem similar in terms of technique, efficacy, and safety, although the suprapapillary stent seems superior in terms of stent patency.

References

Ko SW, Joo HD, Song TJ, Kim S, Choi SJ, Oh CH, Oh D, Park JS, Yoon SB, Yoon JH, Seo DW, Lee SK. Impact of the suprapapillary method on patency in distal malignant biliary obstruction: a multicenter randomized controlled trial. Gastrointest Endosc. 2024 Oct;100(4):679-687.e1. doi: 10.1016/j.gie.2024.03.024. Epub 2024 Mar 21. PMID: 38521477.
Kurita A, Uza N, Asada M, Yoshimura K, Takemura T, Yazumi S, Kodama Y, Seno H. Stent placement above the sphincter of Oddi is a useful option for patients with inoperable malignant hilar biliary obstruction. Surg Endosc. 2022 May;36(5):2869-2878. doi: 10.1007/s00464-021-08576-x. Epub 2021 Jun 2. PMID: 34076770.
Finn Møller Pedersen, MD, Annmarie Touborg Lassen, Ove B. Schaffalitzky de Muckadell. Finn Møller Pedersen, MD, Annmarie Touborg Lassen, Ove B. Schaffalitzky de Muckadell. Gastroint Endosc. 1998;48(6):574-579.

Introduction

In the carcinogenic pathway of colorectal cancer, the first concept is the "adenoma-carcinoma sequence" and the second concept is the " serrated pathway ". In these concepts, adenomas and serrated lesions gradually progress to cancer. The third concept is the "de novo pathway," in which cancer develops without adenomas or serrated lesions and is also characterized by high malignancy and rapid progression. We have endoscopically characterized depressed colorectal cancers considered to be of the "de novo pathway" and validated the usefulness of pit pattern and EC classification.

Aims & Methods

A total of 54819 colorectal neoplasms were resected endoscopically or surgically in our institution from April 2001 to December 2024. They were subjects of this study. Advanced cancers were excluded. Of these, 1694 lesions were submucosally invasive (T1) carcinomas, 7330 lesions were classified as high-grade dysplasia and 39977 lesions as low-grade dysplasia. Morphologically, they were divided into 3 types: depressed, flat, and protruded type comprising 1.0 (%), 46.4 (%),and 52.6（%), respectively. Specifically, the distinctive features of depressed type neoplasms concerning their pit pattern and EC classification were examined. EC classification is a classification for an endocytoscopy that can evaluate pathology, such as nuclear atypia and glandular structure, by magnifying stained cells. EC1a is diagnosed as normal mucosa, EC1b is diagnosed as hyperplastic polyps, and if slit-like glandular ducts or spindle-shaped nuclei are present, it is classified as EC2 and diagnosed as an adenoma or intramucosal carcinoma. If irregularly shaped glandular ducts or nuclei with a high N/C ratio are found, it is classified as EC3a, and diagnosed as intramucosal carcinoma or SM lightly invasive carcinoma. If the glandular ducts are indistinct and the nucleus is irregularly shaped and darkly stained, it is classified as EC3b and diagnosed as SM highly invasive carcinoma.

Results

Most of the flat (91.5%) and protruded type (94.9%) lesions showed type IIIL or IV pit pattern, which are common findings in adenomas. On the other hand, most of the depressed type lesions (92.6%) classified as type IIIs, VI or VN pit patterns, are typically seen in carcinomas. As for endocytoscopy, most of flat and protruded type lesions were identified as EC2 corresponding to adenomas. In contrast, relatively high rates of depressed type lesions were categorized as EC3a (40.3%) and EC3b (52.4%), consistent with invasive carcinomas.
The proportion of T1 carcinomas in depressed type lesions was 58.7%, whereas in flat and protruded type lesions it was 2.5% and 2.5%, respectively. Additionally, 12.0% of depressed type lesions less than 5mm in diameter were T1 carcinomas, whereas flat and protruded type lesions were 0.01% and 0%, respectively.

Conclusion

This study revealed that depressed lesions were classified as type IIIs, VI or VN pit patterns on magnifying endoscopy and as type EC3a or EC3b on endocytoscopy. Lesions with these features or pit patterns tend to invade the submucosal layer even if they are small size. Despite their high potential for malignancy, depressed lesions are often ignored. However, it is critical to recognize their features and accurately diagnose lesions based on morphology, pit pattern, and EC classification.

Disclosure

Shin-ei Kudo and Masashi Misawa received speaking honoraria from Olympus Corporation and have an ownership interest of the products of Cybernet Systems. Tetsuo Nemoto received a research grant from Olympus Corporation for other studies. Other authors have nothing to declare.